7|P age

Cold abscess of Sternum: Reports of two cases

Email: sandesh.madi@gmail.com

SANDESH MADI , SANDEEP

NAIK , SHARATH RAO
1

VIJAYAN ,
1

MONAPPA

Department of Orthopaedics, Kasturba Medical college, Manipal Univer-

ABSTRACT

sity, Manipal, Karnataka, India

Received

16 April 2015

Accepted 22 May 2015

Introduction
Sternal involvement is seen in less than 1% of skeletal
tuberculosis. Sternal TB was first reported in 1918 [1] and
until 2007, fewer than 35 cases are documented in English
literature [2]. Even in tubercular endemic belts, there are
only limited and isolated case reports [3]. We report two

Sternal bone affection by Mycobacterium tuberculosis is

a rare entity. Clinical manifestations can vary widely.
There are only a few isolated case reports of tubercular
sternal osteomyelitis in both endemic belts and otherwise. We report tubercular abscess of sternum in apparently two healthy young individuals with no predisposing factors, who presented to us with chief complains of
chronic anterior chest pain. Diagnosis was confirmed by
histo-pathological and microbiological work-up. Combined surgical drainage and anti-tubercular drugs gave
satisfactory outcomes. A high index of suspicion for
tuberculosis is necessary whenever unusual sites are encountered in order to facilitate early diagnosis and
prompt management.

cases of tubercular abscess of sternum in otherwise

healthy individuals. Both cases were diagnosed relatively

KEY WORDS:

early in the course of the disease and responded well to a

combined medical and surgical treatment with no recurrence or complications at one year follow up.

Tuberculosis
Cold abscess
Sternum
Chest pain
Drainage

Case 1

Case 2

A 22 year old student was referred to the Orthopedics de-

A 31 year old architect presented to OPD with chief com-

partment with history of dull aching and left sided anterior

plains of vague anterior wall chest pain of four months

chest wall pain of six months duration. She had apparently

duration. Patient also noticed a localized bulge over the

consulted a general practitioner for this complaint, but the

medial aspect of right clavicle for past one month. There

diagnosis was elusive, as the chest X-ray was apparently

was no history of trauma or constitutional symptoms. On

normal and clinical picture did not fit into any medical or

local examination, a solitary, ~5x6cms, firm swelling over

gastroenterological disorder. There was no history of

the manubrium sterni with moderate tenderness was not-

trauma or constitutional symptoms. There was a ~3x2cm,

ed. The chest x- ray was apparently normal and the rest of

firm, non-transilluminant swelling with mild tenderness

systemic examination was also normal. CT of thorax re-

arising from the body of the sternum. There was no re-

vealed

gional lymphadenopathy and systemic examination was

5.1x1.9x8.5cms suggestive of an abscess overlying the

normal. CT thorax revealed irregular lytic destruction of

manubrium sterni and an ill-defined osteolytic lesion with

rd

multi-loculated

collection

measuring

sternal body at level of 3 costochondral junction with an

sclerosis of superior half of manubrium sternum com-

ill-defined abscess measuring 3.3x2.2x2.2cm (Figure 1).

municating with the collection (Figure 2).

Clinical and radiological diagnosis favored the possibility

Correspondence to: Dr Sandesh Madi

ANNALS OF BRITISH MEDICAL SCIENCES. 2015; 1(1): 7-9

of cold abscess in both scenarios and a formal incision and

8|P age

drainage was performed. The purulent material and ne-

Figure 2. CT sagittal view of case 2 showing involvement

crotic tissue samples were sent for histopathological and

of manubrium sterni and cold abscess tracking to subcuta-

microbiological analysis which confirmed the tubercular

neous plane

pathology. The investigational work up of the two cases is

compared in Table 1. Both patients were started on antitubercular regimen [four drugs for two months followed
by two drugs for 10 months daily]. Patients recovered
completely at the end of 12 months of a close follow-up
with no recurrence or complications.
Table 1: A Comparison of investigational work up of the
two cases.

INVESTIGATIONS

CASE 1

CASE 2

Hb
TLC
DLC

12.0 g/dl
6.4x103 /L
Lymphocytes15.7%
Neutrophils71.6%

11.2 g/dl
8.7x103 /L
Lymphocytes19.7%
Neutrophils-68.2%

ESR

44 mm/hour

63 mm/hour

the primary pulmonary foci or direct contiguous spread

CRP

3.0 mg/L

70.3 mg/L

from the hilar lymph nodes. Typically, in the event of

HIV 1&2
RBS
AFB (pus)
PCR (nested)
Biopsy

Negative
88 mg/dl
Not seen
Positive
Granuloma

Negative
96 mg/dl
Scanty growth
Positive
Granuloma

immunosuppressive states such as HIV/AIDS, diabetes,

Discussion
Tubercular affection of the sternum is known to occur in
less than 1% of all skeletal tuberculosis [2]. Mechanism of
involvement is either lympho-hematogenous spread from

Hb- Hemoglobin; TLC- Total Leucocyte Count; DLC- Differential Leucocyte Count; ESR- Erythrocyte Sedimentation Rate; CRP- C-Reactive
Protein; AFB- Acid Fast Bacilli; PCR- Polymerase Chain Reaction.

chronic kidney disease, corticosteroid/chemotherapy use,

alcohol abuse, severe malnutrition and low socioeconomic levels, a dormant infection gets reactivated and
disseminates resulting in osteoarticular involvement. Sternal TB has also been reported in two exceptional conditions: after sternotomy for cardiac surgeries [4] and fol-

Figure 1. CT scan sagittal view of case 1 showing involvement of body of sternum and presence of sequestrum.

lowing BCG vaccination in infants [5]. Clinically, patient

can

present

with

anterior

chest

wall

swelling,

pre/retrosternal dull aching pain or in long standing cases,

indolent ulcers/discharging sinuses over anterior chest
wall and sternal fracture. Presence of constitutional symptoms can be variable. Differential diagnosis includes numerous diverse disorders such as granulomatous diseases
(sarcoidosis), chronic infections (fungal/parasitic) and
various malignancies (lymphomas and metastasis).
Serological markers of inflammation like ESR, CRP and
TLC are neither specific nor entirely reliable [7]. In the
chest x-ray (PA and lateral views), it is difficult to appreciate the sternal affection. Moreover, radiological signs
occur much later than the presenting clinical features, and
abscesses or sinuses are present much before the focus is
detected [3]. CT scans define the extent of bone destruction, while MRI is useful to determine soft tissue exten-

ANNALS OF BRITISH MEDICAL SCIENCES. 2015; 1(1): 7-9

9|P age

sion. However, neither can confirm the diagnosis and only

Conclusion

biopsy is the gold standard. It is possible to ascertain the

Tubercular abscess of sternum is a rare clinical entity but

diagnosis by fine needle aspiration cytology or marginal

can be detected early owing to its superficial location.

biopsy from an established sinus tract. Under the micro-

Anterior chest pain and swelling are early manifestations,

scope, extensive areas of caseous necrosis surrounded by

which unless appropriately evaluated can lead to serious

lymphocytes and epitheloid cells are typically observed.

complications which are difficult to manage. Exclusion of

PCR for M. tuberculosis complex is a rapid test that

tuberculosis should not be prejudiced based upon age, sex

shows good correlation with histological findings, with an

or immunity status. Long term medical management is the

85% sensitivity and 80% specificity [6]. The surgical role

mainstay of treatment supplemented with surgical drain-

in sternal TB encompasses the drainage of abscess, se-

age of the abscess. A periodic follow-up is warranted to

questrectomy, sinus tract excision and flap reconstruction

monitor the response to treatment and look out for com-

for sternal defects besides an open biopsy. A structured

plications. Informed consent from both patients has been

regimen comprising of four drugs [Isoniazid (300mg),

obtained for publication.

Rifampicin (450mg), Pyrazinamide (750mg) and Ethambutol (800mg)] is the mainstay of treatment. It is usually

Conflict of Interest

initiated with all four drugs daily for two months in the

We declare that we have no conflict of interest.

intensive phase followed by a maintenance phase with

Isoniazid and Rifampicin daily for 10-18 months. However, there is no consensus in terms of drug combinations as

References
1

well as duration of the regime especially in osteo-articular

TB even in endemic belts. Generally, combined clinical

and radiological signs of improvements are taken into

consideration to decide about termination of the regimen.

Clinical signs of improvement include weight gain, decrease in pain and swelling, and healing of sinuses. Radio-

logical signs of healing, however, usually lag behind clinical improvement by several weeks and are all the more
difficult to appreciate in the sternum. Possible complica-

tions of sternal tuberculosis include secondary infection,

fistula formation, spontaneous fractures of the sternum,
compression or erosion of the large blood vessels, com-

pression of the trachea and migration of tubercular abscess

into the mediastinum, pleural cavity or subcutaneous tis-

sues [8]. A close follow up is also essential to monitor

response to treatment, patients compliance, drug resistance and adverse side effects.

ANNALS OF BRITISH MEDICAL SCIENCES. 2015; 1(1): 7-9

Vaughn RT. Acute osteomyelitis of the sternum:

woody phlegmon: osteotomy and drainage. Surg
Clin North Am 1918; 5: 253-262.
Jain VK, Singh Y, Shukla A, Mittal D. Tuberculous osteomyelitis of sternum: a case report. J
Clin Diagn Res 2007; 1: 163-7.
Tuli SM, Sinha GP. Skeletal tuberculosis. "Unusual" lesions. Indian J Orthop 1969; 3: 5-18.
Kim HJ, Kim JB, Chung CH. Chronic Sternum
Wound Infection Caused by Mycobacterium tuberculosis After Cardiac Surgery. Ann Thorac
Surg, 2012; 94(4): 1332-1335.
Kato Y, Horikawa Y, Nishimura Y, Shimoda H,
Shigeto E, Ueda K.. Sternal tuberculosis in a
9monthold infant after BCG vaccination. Acta
Paediatrica 2000; 89(12): 1495-1497.
Vasa M, Ohikhuare C, Brickner L. Primary sternal tuberculosis osteomyelitis: A case report and
discussion. Can J Infect Dis Med Microbiol.
2009; 20(4): 181.
Watts HG, Angrles L, Lifesto RM. Current concepts review: tuberculosis of bones and joints. J
Bone Joint Surg Am. 1996; 78:288298.
Sharma S, Juneja M, Garg A. Primary tubercular
osteomyelitis of the sternum. Indian J Pediatr.
2005; 72(8):709-10.